Collection Information Statement for Businesses

Form 433b: Collection Information Statement for Businesses

Use Tax Form 433b: Collection Information Statement for Businesses as a stand alone tax form calculator to quickly calculate specific amounts for your 2019 tax return. Form 433b: Collection Information Statement for Businesses is also integrated into our comprehensive US Tax Calculator where you can complete and save your calculations for later use. Alternatively you can use one of our Combined Federal and State Tax Estimator to quickly calculate your salary, tax and take home pay.

Collection Information Statement for Businesses

Note: Complete all entry spaces with the current data available or "N/A" (not applicable). Failure to complete all entry spaces may result in rejection of your request or significant delay in account resolution. Include attachments if additional space is needed to respond completely to any question.

Section 1: Business Information

1a

Business Name

2a

Employer Identification No. (EIN)

1b

Business Street Address

Mailing AddressCityStateZIP

2b

Type of entity (Check appropriate box below)PartnershipCorporationOtherLimited Liability Company (LLC) classified as a corporationOther LLC - Include number of members

1c

County

2c

Date Incorporated/Established mmddyyyy

1d

Business Telephone

3a

Number of Employees

1e

Type of Business

3b

Monthly Gross Payroll

3c

Frequency of Tax Deposits

1f

Business Website (web address)

3d

Is the business enrolled in Electronic Federal Tax Payment System (EFTPS) Yes No

4

Does the business engage in e-Commerce (Internet sales) If yes, complete 5a and 5b.

Total Cash in Banks (Add lines 17a through 17c and amounts from any attachments)

$

ACCOUNTS/NOTES RECEIVABLE Include e-payment accounts receivable and factoring companies, and any bartering or online auction accounts. (List all contracts separately including contracts awarded, but not started). Include Federal, state and local government grants and contracts.

Name & Address (Street, City, State, ZIP code)

Status (e.g., age, factored, other)

Date Due(mmddyyy)

Invoice Number or Government Grant or Contract Number

Amount Due

18a

Contact NamePhone

$

18b

Contact NamePhone

$

18c

Contact NamePhone

$

18d

Contact NamePhone

$

18e

Contact NamePhone

$

18f

Outstanding Balance (Add lines 18a through 18e and amounts from any attachments)

Total Equity (Add lines 23a through 23g and amounts from any attachments)

$

BUSINESS LIABILITIES Include notes and judgements not listed previously on this form.

Business Liabilities

Secured/Unsecured

Date Pledged (mmddyyyy)

Balance Owed

Date of Final Payment (mmddyyyy)

Payment Amount

24a

Description:

SecuredUnsecured

$

$

NameStreet AddressCity/State/ZIP codePhone

24b

Description:

SecuredUnsecured

$

$

NameStreet AddressCity/State/ZIP codePhone

24c

Total Payments (Add lines 24a and 24b and amounts from any attachments)

$

Section 5: Monthly Income/Expenses Statement for Business

Accounting Method Used: CashAccrual

Use the prior 3, 6, 9 or 12 month period to determine your typical business income and expenses.

Income and Expenses during the period (mmddyyyy)to (mmddyyyy)

Provide a breakdown below of your average monthly income and expenses, based on the period of time used above.

Total Monthly Business Income

Total Monthly Business Expenses

Income Source

Gross Monthly

Expense items

Actual Monthly

25

Gross Receipts from Sales/Services

$

36

Materials Purchased

$

26

Gross Rental Income

$

37

Inventory Purchased

$

27

Interest Income

$

38

Gross Wages & Salaries

$

28

Dividends

$

39

Rent

$

29

Cash Receipts (Not included in lines 25-28)

$

40

Supplies

$

Other Income (Specify below)

41

Utilities/Telephone

$

30

$

42

Vehicle Gasoline/Oil

$

31

$

43

Repairs & Maintenance

$

32

$

44

Insurance

$

33

$

45

Current Taxes

$

34

$

46

Other Expenses (Specify)

$

35

Total Income (Add lines 25 through 34)

$

47

IRS Use Only-Allowable Installment Payments

$

48

Total Expenses (Add lines 36 through 47)

$

49

Net Income (Line 35 minus Line 48)

$

1 Materials Purchased: Materials are items directly related to the production of a product or service. 2 Inventory Purchased: Goods bought for resale.3 Supplies: Supplies are items used to conduct business and are consumed or used up within one year. This could be the cost of books, office supplies, professional equipment, etc.4 Utilities/Telephone: Utilities include gas, electricity, water, oil, other fuels, trash collection, telephone, cell phone and business internet.5 Current Taxes: Real estate, state, and local income tax, excise, franchise, occupational, personal property, sales and the employer's portion of employment taxes.

Tip: use the US Tax Calculator to edit your refundable and non-refundable tax credits including Form 433b: Collection Information Statement for Businesses. Complete, Calculate, print and or save your tax calculation for later use.